Rita Shane, Pharm.D., FASHP, FCSHP Chief Pharmacy Officer Cedars-Sinai Medical Center Asst. Dean, Clinical Pharmacy, UCSF School of Pharmacy

• Describe the transformation of health-systems in response to changes in the healthcare landscape

• Cite recent evidence supporting advanced roles for pharmacists and technicians

• Describe the pharmacist’s role in ensuring safe transitions of care

• Identify essential aspects of managing complex, chronic diseases

Traditional Acute Care Focus

Health and Wellness Focus • Episode-based • Medical care • Treatment of acute conditions • Admissions • Medication orders • Outpatient revenue • Oral medications mainstay for

chronic diseases

• Patient-centered care • Team-based care • Preventing readmissions • Transitions of care • Patient’s medication list • Outpatient costs • Biologics infusions, injections and

therapeutic advances for chronic diseases

• “Principles Supporting Dynamic Clinical Care Teams-American College of Physicians Position Statement,” Sept 2013

• Shift from clinicians practicing independently to groups of MDs, RNs, PAs, clinical pharmacists, social workers and other clinicians to better meet patient needs

• Nimble, adaptable partnerships to encourage teamwork, collaboration and smooth transitions of responsibility

• Matching pt with team member(s) most qualified to deliver care • Collaborative team models needed to address MD shortages

.

Doherty RB, Crowley RA. Ann Intern Med 2013; 159

• “ Team-Based Care Initiatives • Transitions of Care Programs to reduce readmissions

• BOOST (better outcomes for older adults through transitions of care) focusing on the elderly

• Project RED (re-engineering discharge) • Medical Homes: integrating pharmacists into teams

• “Why Pharmacists Belong in the Medical Home”, 2010 Health Affairs • Iowa Family Medicine: Significant improvement in BP control • Asheville Project: Significant improvement in HA1c and BP control and

reduced costs 1. http://www.hospitalmedicine.org/AM/Template.cfm?Section=Home&TEMPLATE=/CM/HTMLDisplay.cf

m&CONTENTID=27659 2. http://www.bu.edu/fammed/projectred/ 3. Smith MA, Bates DW, Bodenheimer T, et al . Health Affairs. 2010; 29(5): 906-10

• Center for Medicare and Medicaid Services (CMS) expansion of the definition of medical staff to include pharmacists along with other health professionals, 2012

• “Pharmacists with advanced clinical knowledge collaborating with physicians, nurses and other members of the team improve medication outcomes”, Regina Benjamin, U.S. Surgeon General • 2011 report to the U.S. Surgeon General: U.S. Pharmacists’ Effect as Team

Members on Patient Care

• National efforts to achieve provider status; recently granted in California

http://www.ashp.org/DocLibrary/Advocacy/Provider-Status.aspx, accessed 7/28/13. http://www.usphs.gov/corpslinks/pharmacy/sc_comms_sg_report.aspx, accessed 9/8/13.

Smith M, Bates DW, et al. Health Affairs. 2013; 32(11): 1963-70

• Medications are cornerstone for chronic disease mgmt • MDs don’t have time to take a complete medication

history • MDs spend an average of 49 seconds discussing a

new prescription during an office visit • Poor communication at care transitions contributed to

50% of all hospital-related medication errors and 20% of adverse drug events

Smith M, Bates DW, et al. Health Affairs. 2013; 32(11): 1963-70

• Up to 67% of patients admitted to the hospital have unintended medication discrepancies • Review of 12 studies demonstrated that 45% of patients had at least 1 clinically significant discrepancy

• Nearly 23% of pts discharged have an adverse event of which 72% are medication-related • 51% of pts had at least 1 clinically important medication error during

the first 30 days post-discharge; approx 13% resulted in ED visit or readmission

• Clinicians rely on the information and prescribe medications that are listed even though the information may be inaccurate

Kwan, JL; Lo, L. Medication Reconciliation During Transitions of Care as a Patient Safety Strategy. Ann Intern Med. 2013;158:397-403.

Errors introduced in any of these settings can become “hardwired” into the pt record

MD Office/ Outpatient Settings • Certified

medical assistants

• Physicians • Community

pharmacies • Patients

ED/Hospital • Nurses • Physicians • Pharmacists • Pharmacy

technicians • Pharmacy

residents, students

Home/Skilled Nursing Facility • Nurses

Ensuring Safe Medication Transitions

Medications Prior to Admit Medication List AND New Orders Drug Indication Dose Route Frequency Dosage form Duration

Patient Characteristics Age (pediatrics/ geriatrics) Gender Height/Weight Allergies Kidney/Liver Function Current labs Previous admissions

Current Medication List Drug-drug interactions Drug-disease interactions Drug-food interactions Duplicate therapy Contraindications Medications needed but not prescribed Monitoring requirements

Special Considera-tions High risk patients or therapies such as: Chemotherapy Pediatrics ICU Blood thinners Antibiotics

• Novant Health's Safe Med Program • Post-discharge follow up of high risk pts by pharmacists including

medication reconciliation, education and f/u with MDs • 30-day readmission rate ↓ from 13.1 to 6%; 60-day rate ↓ from 7.7 to

2.7 % • Hennepin County Medical Center Program for Patients

Discharged to Skilled Nursing Homes • Team approach to medication reconciliation and medication therapy

management visits by pharmacists for high risk pts • 50%↓ in readmission rate from 10.2% to 5.4%; results sustained over 4

years • No medication errors compared to 1 error in 70% of pts at baselines

http://www.innovations.ahrq.gov/content.aspx?id=2959, accessed 12/15/13 http://www.innovations.ahrq.gov/content.aspx?id=3111, accessed 12/1/13.

Ensuring Accurate

Medication Handoffs

Inpatient PTA Medication

Reconciliation Skilled Nursing Facilities

Hospitalist Program

ED PTA Medication

Reconciliation

Congestive Heart Failure

PTA: Prior to Admission

Continuum of care PTA medication reconciliation for high-risk populations

Identify High-Risk Patients

Validate Medication

List ∙∙∙∙

Assess Adherence

and Literacy

∙∙∙∙

Educate Patient

Notify MD of Drug-Related

Problems and

Recommend-ations

Post-Discharge Follow-Up

within 72 Hr -Med Rec

-Adherence & Literacy Reinforce-

ment -Education

Additional Calls up to

30 Days Based on

Risk Assess-

ment

Objective: Evaluation of Medication List, Adherence, and Literacy

Adherence Literacy 1. Do you ever forget to take

your medicine? 2. Are you careless at times

about taking your medicine? 3. When you feel better do you

sometimes stop taking your medicine?

4. Sometimes if you feel worse when you take the medicine, do you stop taking it?

1. Name of medicine? 2. Indication of medicine? 3. Strength of medicine? 4. Frequency/directions of

medicine? Cutler, DM; Everett, W. Thinking Outside the

Pillbox — Medication Adherence as a Priority for Health Care Reform. N Engl J Med 2010; 362:1553-1555

• Pts with low adherence and literacy who received post-discharge follow up had a 14% readmission rate compared to 42% who did not receive follow up

• 2013 Enhanced Care Program for skilled nursing facility (SNF) patients • 25% ↓30-day readmission • Post-discharge medication reconciliation completed for 620 pts • 455 serious/significant drug-related problems identified in 39% of

patients

18

Reason for Admission

Drug-Related Problems Identified Post-Discharge and Pharmacist Intervention

Adverse Outcome Prevented

90 y/o F w/ Afib and CHF.

Issue discovered: Pt discharged on supra- therapeutic home warfarin dose. Intervention: Recommended inpt dose and checking INR ASAP.

Avoided increased risk of bleeding d/t 3-fold dosing error.

89 y/o F w/ Type 2 DM and DVT.

Issue discovered: Pt discharged on Xareltro® BID but was receiving daily at SNF. Erroneous Amaryl® and Lantus® continued. Intervention: Recommended to change Xareltro® to BID w/ meals, and after 3 wks, 20mg PO daily. D/c Amaryl® and Lantus®.

Avoided morbidity and possible mortality due to hypoglycemia and progression of DVT to potential PE.

79 y/o M w/ ESRD w/ S. aureus bacteremia.

Issue discovered: No order was given to dialysis center for vancomycin. Intervention: Ensured vancomycin administration occurred.

Avoided progression of bacteremia.

• High cost chronic disease • Targeted cellular therapies add costs and require

special knowledge and skills • Oral chemotherapy agents are transforming cancer

care and require close follow up to manage side effects, ensure adherence and prevent drug interactions

• Lack of health literacy is a major challenge for cancer patients

• Oncology pharmacy specialists participate in team-based care

• Episode payment being piloted • Health-systems are acquiring oncology practices in

response to reduced chemotherapy margins and to advance integration of care

• Oncology medical home models of care • Pain management, palliative care and end of life

management are patient care and economic priorities

• Used to treat complex, chronic diseases such as multiple sclerosis, cancer, Crohn’s disease, rheumatoid arthritis and orphan diseases

• Expensive: $20,000 to >$200,000/yr • Generally injectable medications which need to be

infused but can also include oral medications • Represent 1/3 of national total drug costs

• $75.8 billion in 2010 • >20% growth/year

22

1. Owens GM. New FDA approvals for 2013: a 15 year high. American Health and Drug Benefits.2013; 6(3): 9-12.

2. White Paper. Excelera Specialty Pharmacy Network. 2012 ExceleraRX, LL 3. http://www.prnewswire.com/news-releases/specialty-drugs-will-account-for-50-

percent-of-all-drug-costs-by-2018-201037011.html.

• 907 drugs in biotech pipeline • Anticipate that by 2017 will account for 50% of a health

plan’s pharmaceutical expenses • Represents 1-5% of population • Patients generally have other chronic conditions • Require ongoing monitoring and patient follow up to

ensure adherence and prevent adverse events

• Essential patient care components: • Complete and accurate medication lists • Comprehensive patient and medication evaluation • Determining optimal location for medication administration • Patient education, ongoing follow-up and coordination of medications

Multiple medications with risk for adverse

events

Multiple pharmacies and locations to

obtain/administer medications

Patient medication literacy, adherence

and financial burden

Medication Ordered Outcome Avoided

Order for toclizumab for rheumatoid arthritis at 12.7 mg/kg; however dose should have been 8mg/kg

Continuation of dose at 60% above manufacturer’s maximum dose recommendations; risk of severe, life-threatening infections

Order for nataluzimab; medical record review revealed previous anaphylactic (life threatening allergy) reaction

Potentially life-threatening allergic reaction

Order for infliximab in patient with order for a herpes zoster (live shingles) vaccine

Potential development of active shingle infection

Order for infliximab with potential tuberculosis based on PPD results

Potential exacerbation of infection and employee exposure

• Pharmacist across all settings should ensure the accuracy of the medication list

• Pharmacists across the continuum of care should be actively engaged in ensuring handoffs occur especially for high risk patients

• The pharmacist should be the member of the team who is responsible for ensuring medication literacy and adherence

• Pharmacists should be the provider responsible for ensuring the safety and effectiveness of the patient’s pharmacotherapy plan • Evaluation and simplification of chronic medication regimens should be a priority focus area

• At a minimum, all patients should have an annual review of their medication lists by a pharmacist

Practicing at the top of our license*

Being Bold

Pushing Traditional Boundaries

Recognition as an

essential team

member

Patient demand for pharmacist-

directed medication

management

*ASHP Pharmacy Practice Model Summit